Dental Coverage Deciphered, And The Latest On Sign-Up Deadlines

Laura Breland gets her teeth cleaned by Denise Lopez-Rodriguez at a community health center in Aurora, Colo., in 2012. Dental coverage is available through the Affordable Care Act.

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Originally published on January 9, 2014 2:01 pm

New Year's Day marked the halfway point to sign up for health insurance through the Affordable Care Act for coverage this year.

And after a dismal start, things seem to be going a lot better on the HealthCare.gov website. Federal officials say more than 1 million people enrolled in coverage by the Christmas Eve deadline for coverage that began January 1.

People have until March 31 to purchase a plan, or enroll in Medicaid if you're eligible. If you're uninsured after that, you may be subject to a tax penalty in 2015.

But even with things going better, people still have a lot of questions --so many that we've created a searchable list of FAQs so it's easy to find the information you need. We'll be adding to it in the coming days and weeks. Here are more questions from this month's mailbag.

Like a lot of people, Catherine Baer of Poughkeepsie, N.Y., is still a bit confused about deadlines. "If one were to sign up in January, when would the coverage start?" she writes. "Let's say one signed up on January 10, 2014."

People can be forgiven for being confused about deadlines, because they keep changing. But at least for now, they're supposed to work like this: As long as you sign up by the 15th of the month, your coverage starts on the first of the month after that. So if you sign up by the 15th of January, your coverage starts February 1. If you sign up on the 16th of January, though, you'll have to wait until March 1. Same with February; sign up by the 15th and your start date is March 1, but enroll February 16th and you'll have to wait until the first of April. Open enrollment ends March 31. Those people's coverage won't start until May 1.

Ami Rowland of Brighton Colo., wonders about dental coverage. "Do I have to purchase dental insurance for my entire family or can I purchase it just for my son?"

When it comes to dental coverage, the people who designed the benefits decided to split things up based on age. There have been a lot of complaints about there being too many benefits in the minimum package, making coverage more expensive. For that reason, only dental coverage for children is among the required benefits. But if you don't buy it, you won't be penalized. That's different than other required benefits.

So the answer to Ms. Rowland's question is if her son is a child, she can get dental coverage just for him.

But not all states are including dental coverage in health plans. And it can be hard to find out if it's included, though some states are trying to make that easier. In Colorado, for instance, health plans that include children's dental coverage are designated by a colored tooth icon.

If dental isn't included in a plan, you can buy standalone dental coverage. That coverage is also available for adults in most areas.

Anne Vanderhorst of Lexington, Ky., wants to know about the tax penalty for people who decide not to get health insurance. "If you do get covered at some point during 2014, is the penalty prorated or does it not matter?" she asks.

Now that it's 2014, most people will have to have health insurance or be subject to that penalty we've been hearing so much about. This first year the penalty is fairly small — if you're without insurance for the entire year it's the larger of $95 or 1 percent of your income (taxable income in excess of the IRS filing threshold) for an individual. It goes up in future years.

If you don't have insurance, you have until the end of March to buy coverage and still avoid the penalty. That's because you can be without insurance for up to three consecutive months before penalties are applied. If you don't earn enough to file income taxes, you're not subject to the penalty.

The penalty is prorated on a monthly basis. For every month you lack insurance beyond three months, each family member pays a monthly penalty.

Here's a slightly different question on penalties, from Chris Rickels of Covington, Ky. "I'm a part-time worker and my current employer offers health insurance that does not meet the minimum standards of the Affordable Care Act," he writes. "I talked to someone at the call center for the Affordable Care Act and was told that as long as I had health insurance through my employer I would not be fined. So I bought that insurance and now I'm hearing differently from my coworkers, and that I might be fined."

No, the call center operator was correct. As long as you have any employer-provided insurance, you're OK, and exempt from any fines. Once the requirement for employers to provide coverage takes effect, the employer might not be, but that's been put off until 2015. If Mr. Rickels wants to drop his employer coverage and go to the exchange and buy a more comprehensive plan, assuming his employer-based coverage doesn't cover 60 percent of typical health expenses, he would probably be eligible for a subsidy. That's also assuming that he doesn't earn more than four times the poverty level — about $46,000. But if he's just worried about avoiding any penalties, then he's fine.

Robert Dodelin of Mount Laurel, N.J., is losing his current health insurance this month and will be shopping on the exchange. He wants to know what financial information he'll need to provide.

This is an excellent question, because it turns out there's quite a bit of paperwork involved. And that's even though health plans can't ask you about your medical history any more. To figure out of you're eligible for a subsidy to help pay premiums, they want to know a lot about who you are and how much you earn.

You'll need to provide proof of identity, either your Social Security number or legal immigrant status. You'll need employer and income information, which can include pay stubs or W-2 forms or, if you're self-employed, last year's tax return. The application also asks for information about any employer health insurance that's available to you or members of your immediate family, because that affects your eligibility for government help paying for individual insurance. So gather all that stuff up before you go to the web site or meet with someone who's helping you apply for coverage.

Finally, George Elgee of Juneau, Alaska, wants to know, "Can employers pay for insurance that employees buy on their own, either from the exchange or from private people?"

That sounds like a pretty straightforward question, but it turns out that Mr. Elgee is a CPA, and what he really wants to know is whether employers, particularly small employers, can reimburse workers who buy their own insurance and then the employers could take a tax deduction for doing that. It seems the answer is probably not.

There are lots of provisions in the law to encourage small employers to purchase coverage directly for their workers. There's a new tax credit for very small employers who have mostly lower-wage workers. This year that's set to cover 50 percent of the cost of coverage. And there's something called the SHOP exchange, where businesses are supposed to be able to go to get a better selection of plans for their employees.

The problem is that with the rocky rollout for the web sites serving individuals, the federal government and most of the states have put the small business part of the program on the back burner.

That may be why some small employers want to give their workers extra money and let the workers buy their own coverage. But tax experts say that may not be the best way to help people. That's because the higher a person's income, the less help they will get paying their premium. And that extra money from employers would count as income. So if an employer really wants to help, they might want to put more money into a worker's retirement plan, if they have one, or buy them vision or dental benefits.

Remember, our previous questions and answers about Affordable Care Act coverage, as well as our frequently asked questions, are now searchable at npr.org/ACA. If you don't find your answers there, send your questions to health@npr.org, and we'll try to address them in our next round of answers.

Copyright 2014 NPR. To see more, visit http://www.npr.org/.

Transcript

DAVID GREENE, HOST:

This is MORNING EDITION from NPR News. Good morning, I'm David Greene.

Today in Your Health, we're answering more of your questions about the Affordable Care Act. And a lot of questions there have been. Things do seem to be going a lot better on the healthcare.gov website. Federal officials say more than a million people enrolled in coverage by the Christmas Eve deadline. That was if people wanted their coverage to begin on January 1st.

But there are a lot of questions about the deadlines and a lot more, and so we've brought in NPR's Julie Rovner who is back to give us some answers. Hey, Julie.

JULIE ROVNER, BYLINE: Hey, David.

GREENE: Ok. So we're passed that deadline. People who wanted the coverage to begin on January 1st, they have their coverage. Now we're moving on to lots of other deadlines, and that's where our questions actually start. One from Catherine Baer of Poughkeepsie, New York. She seems to be confused like a lot of us. She write: If one were to sign up in January, when would the coverage start? Let's say one signed up on January 10, 2014. So how do you answer that?

ROVNER: Well, people can be forgiven for being confused about the dates, because the dates do keep changing.

GREENE: A lot.

ROVNER: Yes.

(LAUGHTER)

ROVNER: At least for now, they're supposed to work like this. As long as you sign up by the 15th of the month, your coverage starts on the first of the month after that. So if you sign up by the 15th of January, your coverage starts February 1st. If you sign up on the 16th of January, though, you'll have to wait until March 1st. Same with February; sign up by the 15th and your start date is March 1st. But wait until February 16th and you'll have to wait until the first of April. Now, open enrollment ends March 31st. Those people's coverage won't start until May 1st.

GREENE: So if you don't sign up by March 31st that's when we start talking about penalties. And that's where actually our next question goes. We have a question from Anne Vanderhorst of Lexington, Kentucky. And she has a question about the tax penalty for people who don't sign up for health insurance.

ANNE VANDERHORST: If you do get covered at some point during 2014, is the penalty pro-rated or does it not matter?

GREENE: OK, Julie, tell us a little about how the penalties work.

ROVNER: Well, now that it's 2014, most people will have to have health insurance or be subject to that penalty we've been hearing so much about. This first year the penalty is fairly small. If you're without insurance for the entire year it's the larger of $95 or 1 percent of your income for an individual. It goes up in future years.

But if you don't have insurance, as we just mentioned, you have until the end of March to buy coverage. That's because you can be without insurance for up to three consecutive months and not pay any penalty. And, yes, Ms. Vanderhorst, the penalty is pro-rated.

The way it will be asked when you fill out your 2015 taxes is whether your had health insurance in 2014 and for how many months. For every month you lacked insurance over three, you pay a penalty, per family member, per month. And if you don't earn enough to file income taxes, you're not subject to the penalty, by the way.

GREENE: Ah, if you're not filing income taxes you're not subject to the penalties. Seems like an important point.

ROVNER: That's a very important point.

GREENE: More questions about the penalty we received, one of them specifically about which plans satisfy the requirement for having adequate coverage. And this question comes from Chris Rickels of Covington, Kentucky.

CHRIS RICKELS: I'm a part-time worker and my current employer offers health insurance that does not meet the minimum standards of the Affordable Care Act. I talked to someone at the call center for the Affordable Care Act and was told that as long as I had health insurance through my employer, I would not be fined. So I bought that hi and now I'm hearing differently from my co-workers and that I might be fined.

GREENE: OK, Julie, so which is it? This gentleman has health insurance through his employer but it's not insurance that satisfies the law.

ROVNER: You know, I had to do a little investigating on this one, just to be sure. And, yes, the call center operator was correct. As long as you have employer-provided insurance, you're OK you're and exempt from any fines. Once the requirement for employers to provide coverage takes effect, the employer might be subject to a fine, but that's been put off a year.

Now if Mr. Rickels wants to drop his employer coverage and go to the exchange and buy a more comprehensive plan, assuming his coverage doesn't cover 60 percent of typical health expenses, he would probably be eligible for a subsidy. That's assuming he doesn't earn more than four times the poverty level - about $46,000. But if he's just worried about not paying the penalty, then he's OK.

GREENE: Seems like there's a new wrinkle everywhere with this law.

So I got an e-mailed question from Robert Dodelin from Mount Laurel, New Jersey. And he is losing his current health insurance this month and will be going to the exchange. And he wants to know about financial information that he'll have to provide when he applies for health insurance. So what documents should people have ready?

ROVNER: This is a really good question because it turns out there's quite a bit of paperwork involved. And that's even though health plans can't ask you about your medical history anymore. But because of the availability of premium subsidies, they want to know a lot about who you are and how much you earn.

So what you'll need is proof of identity; either your Social Security number or legal immigrant status. You'll need employer and income information, which can include pay stubs or W-2 forms; or if you're self employed, last year's tax return. The application also asks for information about any employer health insurance that's available to you or members of your immediate family because that affects your eligibility for government help paying for individual insurance. So gather all that stuff up before you go to the website or before you meet with someone who's helping you apply for coverage.

GREENE: Word to the wise - have it all ready.

So Julie, this next question from Ami Rowland, of Brighton, Colorado is about dental coverage under this law. I feel like it's not something we've talked much about.

AMI ROWLAND: My question is, do I have to purchase dental insurance for my entire family or can I purchase it just for my son?

GREENE: Julie, what's the story here?

ROVNER: That's right. We really haven't talked about dental coverage much. And it's an important benefit to a lot of people who haven't had it before even if they have had health insurance. Dental care can be very expensive. If you have untreated dental problems, it can lead to all sorts of other health problems.

Now this is a place where the people who designed the benefits decided to kind of split things up. We've heard a lot of complaints about there being too many benefits in this minimum package, which has driven premiums up. For that reason, only dental coverage for children is among the required benefit. But in most places you can buy either an add-on package or a separate dental plan if you want to cover adults in your family.

So the answer to Ms. Rowland's question is that assuming her son is a child and not an adult son, yes, she can purchase dental for just him. In fact, any plan on the exchange will cover his dental. She'll have to specifically add dental coverage for the adults in her family if she wants it.

GREENE: If for some as a child that will be required under the law, for him to have dental coverage.

ROVNER: That's right.

GREENE: All right, Julie, another question. This one comes from Juneau, Alaska, from George Elgee.

GEORGE ELGEE: And my question is, can employers pay for insurance that employees buy, on their own from, either from the exchange or private people?

GREENE: OK. The answer?

ROVNER: Well, it sounds pretty straightforward. It turns out Mr. Elgee is a CPA, and what he really wants to know is whether employers, particularly small employers, can basically reimburse workers who buy their own insurance and then the employers would get a tax deduction for it. It seems the answer is probably not.

Now there are lots of provisions in the law to encourage small employers to purchase coverage directly for their workers. There's a new tax credit for very small employers who have mostly lower-wage workers. This year it's set to cover 50 percent of the cost of coverage. Then there's something called the shop exchange where businesses are supposed to be able to go to get a better choice of plans for their employees.

The problem is that with the rocky rollout of the websites serving individuals, both the federal government and most of the states have really kind of put the small business part of the program on the back burner. And where it is operating it hasn't had a lot of traffic, and the few businesses that have tried to use it say they've had some trouble. So at least for now that part of the program really isn't living up to its expectations.

GREENE: And you've actually reported on that - how some of the parts of the law dealing with small businesses are really being pushed aside for a while.

ROVNER: Yeah. And that may be why for now some small employers just want to give their workers some extra money and let the workers buy their own coverage. But in talking to tax experts, they say that may not be the best way to help their workers. That's because the higher a person's income, the less help they get paying their premium and in terms of those subsidies. So if an employer really wants to help, they might want to put more money into a worker's retirement plan - if they have one - or buy them maybe vision or dental benefits.

GREENE: All right, some answers for now. But I think it's safe to say that you and I will be back here soon with more questions and answers.

ROVNER: Indeed.

GREENE: NPR's Julie Rovner. Thanks a lot.

AMY ROWLAND: Thank you.

GREENE: And if we didn't get to your question today, we have more questions, more answers in a searchable app that's on our website. Just go to npr.org/affordablecareact. And if you don't find your answers there, you can also send your questions to health@npr.org.